Anemia in Pregnancy
Rajeev Ojha
Case 1 Mrs.
A. N. is a 28-year-old woman in her second trimester of pregnancy with her first child, and though her pregnancy had been progressing normally, recently she has noticed that she tires very easily and is short of breath from even the slightest exertion. She also has experienced periods of light-headedness, though not to the point of fainting. Other changes she has noticed are cramping in her legs, and the fact that her tongue is sore.
Upon
examining, she has tachycardia, pale gums and nail beds, and her tongue is swollen. Given her history and the findings on her physical exam, she is suspected to be anemic and a sample of her blood is orderes for examination.
Table 1. Blood Sample Results Red Blood Cell Count
3.5 million/mm3
Hemoglobin (Hb)
7 g/dl
Hematocrit (Hct)
30%
Serum Iron
low
Mean Corpuscular Volume (MCV)
low
Mean Corpuscular Hb Concentration low (MCHC) Total Iron Binding Capacity in the Blood (TIBC)
high
A
diagnosis of anemia due to iron deficiency is made and oral iron supplements prescribed. Her symptoms are eliminated within a couple of weeks and the remainder of her pregnancy progresses without difficulty.
Case 2 A
35 year old woman is seen for easy fatigue for many months. She is now 24 weeks pregnant with her 3rd child in 3 years. She does not see any obstetrician and does not take any vitamins. Lately, she has developed a taste for eating ice (craving to taste ice, soil etc). She has no other complaint. Family and past history are negative. She does not smoke or drink. Physical examination is positive for pale conjunctiva, mild spooning of nails, and a II/VI systolic murmur at left lower sternal border. Stools are negative for occult blood.
Labs: Complete
blood count (CBC) - Hb 7.1 gm/dl, Hct 23% - WBC 5,400/mm3 (differential is normal) - Platelets 450,000/mm3 - Mean Corpuscular volume (MCV) is 74 fl (normal 85-95 fl) - Red cell Distribution Width (RDW) is
Defination of Anemia during Preg. Hemoglobin
below 11gm/dl in 1st and 3rd trimester and below 10.5gm/dl in second trimester.
WHO 11gm/dl
By
or less
this standard, 50% of women not on hematinics become anemic.
Incidence Anaemia
may affect 10% of pregnancies in developed countries and is considerably commoner in developing countries, where it is a major source of maternal morbidity and a contributor to mortality. Up to 56% of all women living in developing countries are anaemic (Hb < 11 g/dl) due to infestations.
Classification Physiologic Pathologic:
a. Deficiency: Iron, Folic A., Vitamin B12 b. Hemorrhagic: APH, Hookworm c. Hereditary: Thalassemia, Sickle, H. Hemolytic Anemia d. Bone Marrow Insufficiency: Aplastic Anemia e. Infections: Malaria, TB f. Chronic Renal Diseases or Neoplasm.
Concept of Physiologic Anemia Disproportionate
increase in plasma vol, RBC vol. and hemoglobin mass during pregnancy Marked demand of extra iron during pregnancy especially in second trimester
Criteria for Physiologic Anemia Hb:
10gm% RBC: 3.2 million/mm3 PCV: 30% Peripheral smear showing normal morphology of RBC with central pallor
Significance of Hypervolemia 1. To meet the demands of the enlarged uterus with its greatly hypertrophied vascular system. 2. To protect the mother, and in turn the fetus, against the deleterious effects of impaired venous return in the supine and erect positions. 3. To safeguard the mother against the adverse effects of blood loss associated with parturition.
Normal
hemoglobin by gestational age in pregnant women taking iron supplement
12
wks 24wks 40 wks
12.2 [11.0-13.4] 11.6 [10.6-12.8] 12.6 [11.2-13.6]
Most common causes of Anemia Iron
loss : sweat, repeated pregnancy, hookworm infestation and malaria Faulty absorption mechanism : due to high incidence of intestinal infestation, there is intestinal hurry Faulty diet habit : rich carbohydrate and high phosphate reduce absorption of iron
Factors lead to develop Anemia Increase
iron demand Diminished intake of iron Disturbed metabolism Pre-pregnancy health status Excess demand
Iron Deficiency Anaemia Symptoms: lassitude, weakness, anorexia, palpitation, dyspnea Signs: Pallor, glossitis, soft systolic murmur in mitral area due to physiologic mitral incompetence
Degree:
Mild: 8-10gm% Moderate: 7-8gm% Severe: <7gm%
pallor
Conjunctival Pallor
Koilonychia
Smooth Tongue
Interpretation of plasma Iron
Iron deficiency anemia Anemia of chronic disease Pregnancy
Iron
TIBC
Ferritin
Decreas e Decreas e Increas e
Increas e Decreas e Increas e
Decreas e Increase Normal
Normal Iron Requirements Iron
requirement for normal pregnancy is
1gm 200 mg is excreted 300 mg is transferred to fetus 500 mg is need for mother
Total volume of RBC inc is 450 ml 1 ml of RBCs contains 1.1 mg of iron 450 ml X 1.1 mg/ml = 500 mg
Daily average is 6-7 mg/day
Treatment Prophylactic:
Supplement Fe – 60 mg elemental Fe with Folic
Acid Curative: 200mg FeSo4 3 times daily till Hb level becomes normal, then maintenance dose of 1 tab for 100 days
Megaloblastic Anemia Due
to impaired DNA synthesis, derangement in Red Cell maturation It may be due to Def. of VitB12 or Folic Acid or both. Megaloblastic anemia in pregnancy is almost always due to Folic Acid def. Vit B12 def is rare in Pregnancy becoz its need is less in amount and amount is met with any diet that contains animal products.
Sign and symptoms Insidious
onset, mostly in last
trimester Anorexia and occasional diarrhoea Pallor of varying degree Ulceration in mouth and tongue Hemorrhagic patches under the skin and conjunctiva Enlarged liver and spleen
Angular Cheilosis
Blood values Hb<10gm% Hypersegmentation
of neutrophils
Megaloblast MCV>100micrometer3 MCH>33pg,
but MCHC is Normal Serum Fe is Normal or high TIBC is low
Treatment Prophylactic
- all woman of reproductive age should be given 400mcg of folic acid daily Curative -daily administration of Folic acid 4mg orally for at least 4 wks following delivery
Sickle cell Hemoglobinopathy Hbs
comprises 30-40% total Hb There is substitution of Lysine for glutamic acid at the sixth position of B chain of Hb Red cells in oxygenated state behave normally, but in deoxygenated state it aggregates, polymerises and distort red cells to sickle. These cells are more fragile and increased destruction leads to hemolysis, anemia and jaundice.
Effects on pregnancy Increase
incidence of abortion, prematurity, IUGR and Fetal loss. Perinatal mortality is high. Incidence of pre-eclampsia, postpartum hemorrhage and infection is increased.
Management Careful
antinatal supervision Air travelling in unpressurised aircraft to be avoided. Prophylatically Folic A. 1gm daily. Regular blood transfusion at approx. in 6 weeks interval
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